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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> ►nsin P O Box 7302 <br /> of Commerce <br /> In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> amplete plans(to the county copy only)for the system,on paper not less FT <br /> x3$37 <br /> than 8 1/2 x 11 inches in size. o <br /> e See reverse side for instructions for completing this application (�e(,y)it Number <br /> Personal information you provide may be used for secondary purposes ion io pr ious application L�l' <br /> [Privacy Law,s. 15.04(1)(m)). Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> Prope y Owner Name P1.fil 1402,11011A/A roj/4 <br /> erty Locatio <br /> t/a, ,N,R (� E(o W <br /> Pro a wner's �gA�d�es ,- LottNNerloc Number <br /> �'jj''(( J 92 <br /> Cit State Zi Code P ne ber Subdivision Name orCSl�As umber <br /> N• ( 9 - <br /> II. E OF BUILDING: (check one) ❑ State Owned !tyy Nearest Road <br /> ❑ Vil <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms owlange OF KLJ✓.�T1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 0?4 1100 OZ- �z <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1 ❑ New 2`S�Replacement 3, E] Replacementof 4. E] Reconnection of 5, ❑ Repair of an <br /> System ___System __ _ __ TankOnly______________ Existing System..........ExistingSystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11- Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req it d(sq.ft.) Pro s (sq.ft.) (Gals/d! /sq.ft.) (Min./inch) Elevation <br /> .`, .L? Feet Feet <br /> -PL/ I LOP 1/71451 1VII. TANK Capacity Site <br /> in gallons Total #Of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper_ <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks ow ❑ ❑ ❑ 1:1 0 <br /> Septic Tank or Holding Tank 7W -r-- <br /> Lift Pump Tank/Siphon Chamber ❑ 0 ID ❑ El <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber'sSignatur :(N tamps) MP/MPRSW No.: Business Phone Number: <br /> ,� 22s� & - 415-7 <br /> Plu ber'sAddress(Street,Ci y,State,Zip Code): Q <br /> 1 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater 77_au�m_ <br /> Signature(No Stamps) <br /> surcharge Fee)4)xcro <br /> proved ❑Owner Given Initial <br /> Adverse Determination <br /> NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRI8UTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(R.4/99) <br />